Provider Demographics
NPI:1295208130
Name:DIXON, CASEY GRACE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CASEY
Middle Name:GRACE
Last Name:DIXON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:CASEY
Other - Middle Name:GRACE
Other - Last Name:KUPCHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:767 I AVE
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118
Mailing Address - Country:US
Mailing Address - Phone:609-970-6351
Mailing Address - Fax:
Practice Address - Street 1:1145 STURGIS RD.
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92278
Practice Address - Country:US
Practice Address - Phone:760-830-2190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CA56500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant